[Table of Contents]

Volume: 27S2 • July 2001

Construction-related Nosocomial Infections in Patients in Health Care Facilities
Decreasing the Risk of Aspergillus, Legionella and Other Infections

B.  Risk Assessment and Infection Prevention Measures

A proactive approach is required to decrease the occurrence of construction-related nosocomial infections. The key to eliminating Aspergillus infections is to minimize the dust generated during the construction activity and to prevent dust infiltration into patient care areas adjacent to construction^{(59,75,92,93)}. These activities will also eliminate other dust-borne fungi (e.g. Rhizopus) that may cause invasive fungal infections. Special attention should also be directed to the facility's plumbing system when disruptions occur during construction or renovation projects. Attention to infection prevention measures and ensuring that appropriate personnel are involved are necessary to protect susceptible patients^(56,57).

To provide this protection, preventive measures should be clearly outlined^(13,16) in the contract documents before any construction or renovation project is started, and should be maintained for the duration of the project. A multidisciplinary team, including administrative support, is needed to ensure that the preventive measures are effective^(19,58,94). The responsibilities of all personnel involved in the project need to be clearly outlined in the contract documents in order to identify the liability of all those involved⁽⁵¹⁾. The following section identifies the preventive measures needed to decrease the risk of construction-related nosocomial infections, and discusses strategies to improve communication between ICPs and other professionals.

1.    Risk Assessment and Preventive Measures Checklist

The Risk Assessment and Preventive Measures Checklist is recommended during the design process to assist the multidisciplinary team to identify the patient population at risk and the preventive measures to be initiated. This tool was adapted with permission from the Infection Control Construction Permit developed by V. Kennedy, formerly from St. Luke's Episcopal Hospital, Houston, Texas. The checklist describes four levels of construction activity that may occur within a health care facility and four risk groups, ranging from lowest to highest risk. The project planning committee can use the checklist to identify risk groups that may be affected by their proximity or exposure to the construction zone. With the use of the Construction Activity and Risk Group Matrix, appropriate infection prevention measures are identified by matching the construction activity with the risk group⁽⁹⁵⁾.

The Risk Assessment and Preventive Measures Checklist was adapted from the original source by listing the preventive measures under two categories: construction/renovation activities and plumbing activities. The preventive measures were then further subdivided into categories that represent the personnel responsible for the project (e.g. engineering/maintenance staff). Additional preventive measures suggested in the literature were included. The section on construction activity was expanded to provide more examples. The Infection Control Risk Group was renamed the Population and Geographical Risk Group, and changes were made to the four categories based on suggestions from the literature. Construction-related nosocomial infections should be decreased by the early identification of the population risk group and initiation of appropriate preventive measures.

Instructions on How to Complete

The Risk Assessment and Preventive Measures Checklist is to be completed during the planning design phase of the construction/renovation project by the multidisciplinary planning committee. Infection prevention and control professionals must be involved in each phase of the project to ensure that the appropriate preventive measures are initiated and followed. The type of construction activity is first identified by selecting the level of activity that best describes the project being planned for the health care facility. The types of construction activity are described in Part A. The second step (Part B) involves identifying the population and geographical risk group that may be affected by the project because of its physical proximity or exposure to the construction/renovation activity. There are four groups described in Part B that will help the planning committee to identify the risk group. The appropriate infection prevention measures are identified by matching the construction activity with the population risk group in Part C. As indicated by the shaded areas in the "Construction Activity and Risk Group Matrix", the checklist must be completed and a copy sent to the infection control department to be filed for all Class III and IV categories. Adaptations to the prevention measures can be made only after approval has been provided by the ICP.

Location of Construction:	Project Start Date:	Estimated Duration:
Project Manager (PM):	Contractor(s):	Infection Prevention and Control Professional (ICP):
PM's phone number:	Contractor's phone number:	ICP's phone number:

Yes	No	Construction Activity (see Part A)	Yes	No	Population Risk Group (see Part B)
		Type A: Inspection, non-invasive activities.			Group 1: Lowest Risk
		Type B: Small scale, short duration, minimal dust-generating activities.			Group 2: Medium Risk
		Type C: Activities that generate moderate to high levels of dust, require greater than one work shift to complete.			Group 3: Medium to High Risk
		Type D: Activities that generate high levels of dust, major demolition and construction activities requiring consecutive work shifts to complete.			Group 4: Highest Risk

Part A: Types of Construction Activity

Type A	Inspection and non-invasive activities: These include, but are not limited to, activities that require removal of ceiling tiles for visual inspection (limited to 1 tile per 50 square feet), paint- ing (but not sanding), wall covering, electrical trim work, minor plumbing (disrupts water supply to a localized patient care area [e.g. 1 room] for less than 15 minutes), and other maintenance activities that do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.
Type B	Small scale, short duration activities that create minimal dust. These include, but are not limited to, activities that require access to chase spaces, cutting of walls or ceilings where dust migration can be controlled for the installation/repairs of minor electrical work, ventilation components, telephone wires or computer cables, and sanding of walls for painting or wall covering to only repair small patches. It also includes plumbing that requires disruption to the water supply of more than one patient care area (e.g. > 2 rooms) for less than 30 minutes.
Type C	Any work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies (e.g. counter tops, cupboards, sinks). These include, but are not limited to, activities that require sanding of walls for painting or wall covering, removal of floor-coverings, ceiling tiles and casework, new wall construction, minor duct work or electrical work above ceilings, major cabling activities, and any activity that cannot be completed within a single work shift. It also includes plumbing that requires disruption to the water supply of more than one patient care area (e.g. > 2 rooms) for more than 30 minutes but less than 1 hour.
Type D	Major demolition, construction and renovation projects. These include, but are not limited to, activities that involve heavy demolition or removal of a complete cabling system and new construction requiring consecutive work shifts to complete. It also includes plumbing that results in disruption to the water supply of more than one patient care area (e.g. > 2 rooms) for more than 1 hour.

Part B: Population and Geographic Risk Groups

Group 1 Lowest Risk	Office areas Unoccupied wards Public areas
Group 2 Medium Risk	All other patient care areas unless stated in Group 3 or 4 Outpatient clinics (except for oncology & surgery) Admission/discharge units
Group 3 Medium to High Risk	Emergency room Radiology/MRI Post anesthesia care units Labour and delivery (non operating room [OR]) Normal newborn nurseries Day surgery Nuclear medicine Physiotherapy tank areas Echocardiography Laboratories (specimens) General med/surg wards other than those listed in Group 4 Pediatrics Geriatrics Long-term care
Group 4 Highest Risk	All ICUs All ORs Labour & delivery ORs Anesthesia and pump areas Oncology units and outpatient clinics for patients with cancer Transplant units and outpatient clinics for patients who have received bone marrow or solid organ transplants Wards and outpatient clinics for patients with AIDS or other immunodeficiency Dialysis units Tertiary care nurseries All cardiac catherization & angiography areas Cardiovascular/cardiology patients All endoscopy areas Pharmacy admixture rooms Sterile processing rooms Central Processing Dept. Central Inventory Dept.

Part C: Construction Activity and Risk Group Matrix

A copy of the Risk Assessment and Preventive Measures Checklist must be sent to the Infection Prevention and Control Department when the matrix indicates that Class III and/or Class IV preventive measures are required (see shaded areas). Adaptations to the prevention measures can be made only after approval has been provided by the ICP. The ICP should also be consulted when construction activities need to be done on hallways adjacent to Class III and Class IV areas.

Risk Group	Construction Activity
	Type A	Type B	Type C	Type D
Group 1	I	II	II	III / IV
Group 2	I	II	III	IV
Group 3	I	III	III / IV	IV
Group 4	I -III Contact IC to ensure appropriate classification	III / IV	III / IV	IV

Part D: Specifications for Infection Prevention and Control Measures

Class I Date: Initials:	Engineer/Maintenance Staff & Contractors a)    Construction/Renovation Activities        Dust Control* Immediately replace tiles displaced for visual inspection Vacuum work area. b)    Plumbing Activities Schedule water interruptions during low activity (e.g. evenings if at all possible) Flush water lines prior to reuse Observe for discoloured water Ensure water temperature meets the standards set by the health care facility Ensure gaskets and items made of materials that support the growth of Legionella are not being used Ensure faucet aerators are not installed or used Maintain as dry an environment as possible and report any water leaks that occur to walls and substructures Environmental Services a)    Plumbing Activities Report discoloured water and water leaks to maintenance and ICP Medical/Nursing Staff a)    Construction/Renovation Activities        Risk Reduction Minimize patients' exposure to construction/renovation area b)    Plumbing Activities Report discoloured water and water leaks to maintenance and ICP

* Note.  Class II specifications must be followed if dust should be created during the Type A construction activity.

Note.  The above specifications are to be considered in addition to those listed in Class I.

Note. The above specifications are to be considered in addition to those listed in Class I and II.

Class IV	The following specifications are to be considered in addition to those in Class I, II and III
Date: Initials:	Engineer/Maintenance Staff & Contractors a)    Construction/Renovation Activities     1) Dust Control Before starting the construction project erect an impermeable dust barrier that also has an anteroom Place a walk-off mat outside the anteroom in patient care areas and inside the anteroom to trap dust from the workers' shoes, equipment and debris that leaves the construction zone Ensure that construction workers leave the construction zone through the anteroom so they can be vacuumed with a HEPA filtered vacuum cleaner before leaving the work site; or that they wear cloth or paper coveralls that are removed each time they leave the work site Direct all personnel entering the construction zone to wear shoe covers Ensure that construction workers change the shoe covers each time they leave the work site Repair holes in walls within 8 hours or seal them temporarily     2) Ventilation Ensure negative pressure is maintained within the anteroom and construction zone Ensure ventilation systems are working properly in adjacent areas Review ventilation system requirements in the construction area with ICP to ensure system is appropriate and is functioning properly     3) Evaluation Review infection control measures with other members of the planning team or delegate to evaluate their effectiveness and identify problems at the end of the construction project b)    Plumbing Activities If there are concerns about Legionella, consider hyperchlorinating stagnant potable water or superheating and flushing all distal sites before restoring or repressurizing the water system Environmental Services a)    Construction/Renovation Activities     Evaluation Review infection prevention and control measures with other members of the planning team or delegate to evaluate their effectiveness and identify problems at the end of the construction project Infection Prevention and Control Personnel a)    Construction/Renovation Activities     1) Risk Reduction Regularly visit the construction site to ensure that preventive measures are being followed. Wear coveralls and shoe covers when visiting the site.     2) Evaluation Review infection control measures with other members of the planning team or delegate to evaluate their effectiveness and identify problems at the end of the construction project b)    Plumbing Activities If there are concerns about Legionella, consider hyperchlorinating stagnant potable water or superheating and flushing all distal sites before restoring or repressurizing the water system Medical/Nursing Staff Staff are not allowed to visit the construction site. a)    Construction/Renovation Activities     Evaluation Review infection control measures with other members of the planning team or delegate to evaluate their effectiveness and identify problems at the end of the construction project b)    Plumbing Activities Consider using another source of potable water for patients who are at greatest risk until potable water has been cleared for signs of Legionella after major plumbing installation/repairs

Note.  The above specifications are to be considered in addition to those listed in Class I, II and III.

Adapted from Reduce dust and danger during construction. Hosp Infect Control 1997;24:26-29⁽⁹⁵⁾ (with oral permission from Virginia Kennedy, creator of the tool, formerly from St. Luke's Episcopal Hospital, Houston, TX).

2.    Preventive Measures

Preventive measures have been shown to be effective in health care facilities^(4,13,37,96) as well as in commercial and residential buildings⁽⁹⁷⁾ undergoing renovations. In three of these studies^(37,96,97), preventive measures were initiated before renovations began. After implementing the measures, Overberger and colleagues collected air samples from various locations both within and outside the construction zone before, during, and after the construction (30 weeks)⁽³⁷⁾. In the construction zone, total particulate concentrations and spore counts rose steadily and then declined at the end of the construction, whereas in adjacent patient care areas total particulate concentrations and spore counts did not change significantly from baseline levels. Thus, preventive measures were effective in protecting patient exposure to high levels of airborne particulates and fungal spores generated during construction⁽³⁷⁾. In a similar study, Streifel and colleagues demonstrated that preventive measures reduced infiltration of fungal spores when a building adjacent to the hospital was demolished⁽⁹⁶⁾. Concentrations of airborne microorganisms decreased during the testing of three commonly used methods to minimize dust and prevent migration of dust particles into adjacent areas⁽⁹⁷⁾. The three methods tested were as follows:

• a plastic barrier from the floor to the ceiling to isolate the construction zone plus negative pressurization;
• a plastic barrier and a high-efficiency exhaust fan with a HEPA filter; and
• a plastic barrier and a portable exhaust fan with a side-draft hood.

The second method was the most effective in reducing concentrations of airborne microorganisms in the construction zone and preventing migration of dust particles to adjacent office areas⁽⁹⁷⁾. Neither airflow rates nor the placement of plastic barriers in relation to the true or false ceiling were described in the study.

In two studies, the preventive measures were initiated after the outbreak of a nosocomial fungal infection^(4,13). Before implementation of the preventive measures, the incidence density for nosocomial aspergillosis during construction was 9.88 per 1,000 days at risk, as compared with baseline levels of 3.18 per 1,000 days at risk⁽¹³⁾. Following implementation of the control measures, the incidence density decreased to 2.91 per 1,000 days at risk during construction⁽¹³⁾. Opal and associates reported similar findings. There were no additional cases of disseminated aspergillosis after infection prevention measures had been started, as compared with 11 cases that had occurred before the measures were implemented⁽⁴⁾.

The evidence shows that preventive measures are effective in decreasing the incidence of construction-related fungal infections and that they are cost-effective, because the patients' safety was maintained and further cases were prevented.

Several other preventive measures have been reported:

• Superheating and hyperchlorinating the hospital's hot water system, thus preventing further cases of nosocomial pneumonia caused by Legionella bozemanii. It was believed that L. bozemanii entered the hospital's water supply during the installation of new plumbing at the construction site⁽³²⁾.
• During periods of excavation on hospital grounds or when the plumbing system has been shut down and is later repressurized:
  1) hyperchlorination of stagnant potable water, to be carried out before repressurization;
  2) reporting of persistent discoloured water to maintenance personnel and the infection control department;
  3) culture of the water supply for Legionella in areas housing immunocompromised patients⁽³⁴⁾.
• Ongoing routine Legionella surveillance to allow for comparison of results before, during, and after construction.
• Selection of plumbing materials that do not promote the growth of bacteria and are resistant to corrosion^(45,98,99).
• Removal of faucet aerators and other obstructing and stagnating features such as long pipe lines and dead-ends^{(32,45,80,99)}.
• Assessment of hot water temperature to ensure that it meets the standards set by the health care facility⁽⁹⁹⁾.
• Establishment and implementation of a regular program of preventive maintenance^{(32,54,80,99)}.

The following situation highlights the importance of vigilance with respect to the preventive measures. There was a sudden increase in the number of cases of legionnaires' disease reported in a hospital after its emergency water pump failed⁽³¹⁾. The water pressure dropped for only a few minutes, but the water remained discoloured for up to 4 weeks. In an attempt to recreate the change in water colour, the water supply to one wing was turned off for 5 minutes and then turned back on. Compared with a sample taken before the water supply was turned off there was a 30-fold increase in the concentration of Legionella pneumophila in a second water sample taken after the water supply had been turned back on⁽³¹⁾.

Preventive measures are listed in Table 4, categorized according to phase: preconstruction, construction, and post construction. The multidisciplinary planning committee should select preventive measures according to the activity planned, its duration, and the patient population that may be affected by the construction or renovation project. The committee should understand the risks and respond with appropriate measures. When high risk populations are involved, the infection control department should be notified even for minor construction activity. For example, if the activity involves drilling holes in the walls of a bone marrow transplant unit, the ICP should be notified to ensure appropriate preventive measures are in place.

3.    Personnel Involved

The need to understand the responsibilities of the personnel involved in the project and to establish and maintain clear lines of communication between them and ICP is important in the prevention of construction-related nosocomial infections^(52,59,60). Infection control professional participation during the planning stage is key to the prevention of nosocomial infections.

Familiarity and involvement with the capital planning process will help ICPs become equal partners in construction or renovation projects in health care facilities. The ministries of health for most of the provinces and territories have developed a capital planning document that health care facilities must follow, based on the total cost of the construction and renovation project. This planning document ensures that 1) resources are used efficiently and effectively; 2) the approval process is streamlined; and 3) the key participants' roles and responsibilities are identified⁽¹¹¹⁾. Although the documents are different for each of the provinces and territories, the principles are the same. After a needs assessment, health care facilities submit a proposal to the Ministry of Health, outlining the need for the project and how it will fit into the general long-term plans of the facility and the region. If the proposal is accepted, schematic plans are developed and revised as the project advances. Approval of the final contract documents are sought from the Ministry of Health before bids from the documents are tendered. Construction begins after approval of the contract award by the province's or territory's Ministry of Health. Commissioning is the final phase. This involves ensuring that the construction or renovation activity was completed according to the plan and all systems are functioning properly^(111-115).

ICPs will be more successful in their efforts if they know who are the key players and what are their roles, and if they educate those players about the need for preventive measures to decrease construction-related infections. The ICP should be aware of the roles of the following personnel involved in the project: 1) facility owners and their agents and employees; 2) architects, engineers, constructors, contractors, subcontractors, building trades and suppliers (D. Ardiel, Architect, London, ON: personal communication, 1998). Additional personnel have legal rather than contractual rights and responsibilities. These include building, fire and zoning officials, and provincial ministry officials.

The following section briefly describes the responsibilities of some of the key professionals involved in construction and renovation projects in health care facilities and how collaboration with the infection control professional can decrease the risk of construction-related nosocomial infections.

1.    Facility Owners, Their Agents and Employees

a.    Administration

Administrative support is essential for the successful completion of the construction project. Administrators should ensure that there are policies and procedures within the health care facility that clearly outline the responsibilities of participants in the construction project and the necessary infection control preventive measures. ICP can provide administrators with information on infection control concerns and the importance of preventive measures to assist in the development of the policies and procedures.

b.    Facility Project Managers

The facility project manager is the representative of the health care facility that is undergoing the construction or renovation⁽⁹⁴⁾. His or her responsibilities include overseeing and coordinating the activities of all personnel involved in the construction project and managing information flow among them (D. Ardiel, Architect, London, ON: personal communication, 1998). Facility project managers are also responsible for deciding who should be represented at the planning and design development meetings⁽⁹⁴⁾. They have a key role in construction or renovation projects in health care facilities.

The ICP should develop close working relationships with the facility project managers in their health care facility, who could be educated about infection control concerns and the importance of preventive measures in decreasing construction-related nosocomial infections. The infection control department should be involved during the planning and design development phase of the capital planning process. In addition, the person whose responsibility it is to stop the construction project if there is a significant breach in the preventive measures should be established and incorporated into the contract documents at the time the construction project is planned. Infection control has a role in making sure the project managers have adequate information on which to make a decision.

c.    Environmental Services

Environmental service staff, either facility or contract, are responsible for keeping areas adjacent to the construction zone clean and clear of debris and for thoroughly cleaning the construction or renovation area before the patients are readmitted into these areas^(1,5,7,21). In some circumstances, the contractor is responsible for cleaning adjacent areas. Before the construction project is started, it should be clear who is responsible for cleaning adjacent areas - either the contractor or environmental services. The ICP can collaborate with environmental service staff during the construction phase of the capital planning process by making recommendations on the appropriate cleaning procedures that they should be using in areas adjacent to the construction site.

d.    Medical and Nursing Staff

Medical and nursing staff are responsible for maintaining the patients' health and safety during the construction or renovation project. They should be aware of patient populations at risk, potential hazards that construction/renovation activities pose to patients, and the relevant preventive measures. The ICP can collaborate with the medical and nursing staff to identify patients considered at risk of acquiring construction-related nosocomial infections⁽⁵⁴⁾, such as those who are immunosuppressed because of their underlying medical condition or medical treatment^{(3,7,15,32,42,81,84,89,91)}. Examples of these patients include oncology patients undergoing cytotoxic chemotherapy, bone marrow and solid organ transplantation patients, dialysis patients, and patients in intensive care units. (Refer to Table 3 for patient risk factors and to Part B: Population and Geographical Risk Groups of the Risk Assessment and Preventive Measures Checklist.) The increased awareness of medical and nursing staff may enhance the initiation of timely investigations for patients suspected of having nosocomial pneumonia⁽⁵⁴⁾ and the identification of deficiencies in dust containment in the facility.

2.    Architects, Engineers, Constructors, Contractors, Subcontractors, Maintenance Staff, Building Trades and Suppliers

ICP should be aware of existing building codes and professional guidelines or standards that address infection control issues⁽¹⁾. A list of standards/codes that may help the ICP is provided in the Appendix. By being knowledgeable of the codes and standards, the ICP can discuss the design of the project with the design team during the planning phase of the capital planning process. To ensure that preventive measures are incorporated into the construction project, the ICP can explain to the architect and other professionals involved in the construction the reasons for and importance of following such measures^(1,109).

The architect is responsible for ensuring that the construction or renovation building design meets the health care facility's building objectives. The architect must comply with professional standards and building and fire codes in the development and design of the construction or renovation project⁽¹¹⁶⁾ (D. Ardiel, Architect, London, ON: personal communication, 1998).

Maintenance staff may be the personnel who perform the work, depending on the type of construction activity that is undertaken. Likewise, engineers may be the personnel who design the project.

Engineers, maintenance staff, and contractors must follow building and fire codes and professional standards when planning and completing construction projects, carrying out construction or renovation projects and repairing structures, equipment and utilities within the health care facility^(54,101). As well, their responsibilities include monitoring and evaluating the ventilation system within the construction zone and adjacent areas to ensure that it is functioning properly, not only before the project starts but also throughout its duration and at completion ^(48,101). This includes assessing the airflow, air pressure, and air exchange rate as well as assessing, cleaning, and evaluating the integrity of filters and ducts⁽¹⁰¹⁾. The maintenance staff and contractors are responsible for creating the dust barrier and helping prevent dust infiltration into adjacent areas during the construction project⁽¹⁰¹⁾. The contractors are also responsible for keeping the construction area clean and clear of debris. If the facility's plumbing system is affected by the construction, the contractors are responsible for monitoring the integrity of the system, assessing it for leaks, or minimizing dead-end reservoirs⁽¹⁰¹⁾. Engineers and maintenance staff can help train contractors in safe construction practices while they are working in health care facilities⁽¹⁰¹⁾.

Since these professionals conduct the construction activity, the ICP should communicate with them throughout the construction phase of the capital planning process. In collaboration with the project managers they are responsible for ensuring that infection prevention measures are initiated and followed for the duration of the project ⁽¹⁾. Thus, the ICP can advise the engineers, maintenance staff, and contractors on appropriate preventive measures for a particular activity. When the project is complete, the ICP should review and evaluate the effectiveness of the preventive measures with other members of the construction planning committee to identify positive outcomes and any problems that may have occurred⁽⁵³⁾.

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